Initial investigation for palpitations in primary care, and when to refer to car

Initial investigations for palpitations in primary care:

• Take a detailed history including frequency, duration, and triggers of palpitations, and any associated symptoms such as syncope or breathlessness.
• Perform a clinical examination including cardiovascular and neurological assessment.
• Record a 12-lead ECG with automated interpretation to identify any conduction abnormalities, arrhythmias, or other cardiac abnormalities.
• Measure lying and standing blood pressure if clinically appropriate to assess for postural hypotension.
• Consider blood tests if indicated by history or examination (e.g., blood glucose if hypoglycaemia suspected, haemoglobin if anaemia suspected).

Referral to cardiology (specialist cardiovascular assessment) should be made urgently (within 24 hours) if any of the following are present:

• ECG abnormalities such as conduction defects, long or short QT interval, ST segment or T wave abnormalities.
• History or signs of heart failure.
• Palpitations or syncope occurring during exertion.
• Family history of sudden cardiac death under 40 years or inherited cardiac conditions.
• New or unexplained breathlessness or a heart murmur.
• Age over 65 years with syncope without prodromal symptoms.

Other indications for referral include suspicion of structural heart disease or arrhythmia based on initial assessment or if postural hypotension is suspected but not confirmed by blood pressure measurements.

Patients with uncomplicated vasovagal syncope, situational syncope, or confirmed postural hypotension without other concerning features may not require urgent referral but should have appropriate follow-up and ECG review within 3 days if not already done.